exception reporting

We all recall with interest Samuel L Jackson’s role in Quentin Tarantino’s film “Django Unchained,” playing the role of the slave manager within the film and reporting to Mr Candie, the slave owner, of any difficulties amongst the slaves.

What is of interest, of course, is that Samuel L Jackson is Afro-carribean himself, whilst the film itself portrays 1858 Texas, depicting the slavery that occurred amongst Afro-carribeans and the inherent acceptability of racism within the society at the time.

His role as an Afro-carribean man, controlling the Afro-carribean slaves, was demonstrated in Samuel L Jackson (named as Stephen within the film) being a slave himself, but in a higher hierarchical position than the other slaves, giving him the privilege within this position to talk back at both Mr Candie and at Django in a way that the other slaves would not dare to.

Thus, whilst Stephen would never have the status and prestige within the film of a Caucasian man in 1858 Texas, he was able to behave under certain boundaries as if he had this status. A further important point to note is that Stephen actually believed he had such status and prestige, due primarily to his loyalty and servitude to Mr Candie’s father, whilst of course, Stephen was never to reach equality within this film due to the racist beliefs of Mr Candie, who justified such beliefs by carving a skull to show how, in his view, the skull of an Afrocaribbean will always differ anatomically from that of a Caucasian man.

I look with interest at the underlying power dynamics taking place within the film with reference to that of the current NHS Junior Doctor crises, which this year has led to industrial action for the first time in history amongst junior doctors over an imposition of the new contract.

I find that doctors are the most interesting profession to study within power dynamics, for they are truly an abused profession.

Particularly, the unfortunate power dynamic played towards doctors by those in power attempting to mask their power, is to try and convince doctors that doctors are in power, that they have influence and that their views are being listened to and taken into consideration, whilst in reality, within the organisation, the majority of doctors often have little power or influence over much other than the management of their individual patients and their views on more broader issues are often ignored.

This masking of power extends to that of the public who assume that doctors are in authoritative positions, holding the strings, in charge of hospitals and the NHS organisation and hence responsible for its failures, whilst actually, the NHS is in the deep claws of a political chess game, of which those who are on the front line and who actually understand the realities of the NHS are pushed to the side, devalued and undermined.

To give an example in current times of how power is imposed and controlled amongst a bright, academically brilliant group of people, let us simply look at the new Junior Doctor contract and the “exception reporting” and “guardian role”.

Within the current Junior Doctors contract, if doctors work an excess of hours, the trusts themselves are financially penalised. The new contract will enforce a method of “exception reporting”, which essentially means that the junior doctors will have to declare through a form based procedure that they have worked over their stipulated hours. This will then come under scrutiny from their educational supervisor (who is also a doctor), who will, (as taken directly from NHS Employers website) “discuss with the doctor what action is necessary to address the exception and to ensure that it remains an exception.” Following this, NHS England has stated “where exceptions become more regular or frequent, a work schedule review will usually be required.“ The guardian (also a doctor), will also be informed, who’s role it is to “oversee the work schedule review process and will seek to address concerns relating to hours worked and access to training opportunities.”

Of course, it is an obvious predictability that the flaw within this system is that the responsibility as to why doctors are unable to keep to their assigned hours will fall into the hands of the individual doctor, or the educational supervisor (a doctor), or the guardian (a doctor), and be blamed on the character flaws, work ethics or competency of the individual junior doctor, rather than that of the Trust, or the work load being unsustainable, or the intense pressures faced on the clinical workforce due to underfunding and understaffing.

Don’t believe me?

Have a look the latest NHS Employers factsheet on Guardian Fines, released only a few months prior to full imposition of the new contract, which states: “In anything other than truly exceptional circumstances, the levying of a fine indicates that the system has failed and that some-one- the supervisor, the guardian or the individual doctor concerned- has failed to discharge his or her responsibilities appropriately“.

What is less obvious than this predictable outcome, however, is the ingenuity of using senior doctors (i.e. the educational supervisor and Guardian) themselves within this process to manage and supervise the individual junior doctor’s exception reporting. The educational supervisor is a senior doctor that needs to sign off the individual junior doctor at the end of each year so that he or she can progress up the system, so this obviously is going to deter junior doctors from raising exception reporting as ultimately it will create more work for their superiors. Apart from this, the emphasis of the role of educational supervisors will be on identifying, as NHS England has stated themselves, that the “exception remains an expection”, otherwise “a work schedule review” will be required, hence placing the educational supervisor in a position of having to scrutinise, ensure the competency of the junior doctor and to “improve” the junior doctor, in order to demonstrate that attempts were made in ensuring that this remains an exception, rather than being able to redirect the problem to its probable cause which is that of the organisation the doctors work for.

I argue here the similarities of power structures between that of the new junior doctor exception reporting process and that used within Django Unchained. This may sound far-fetched, making a comparison to junior doctors and historic times of slavery, but I mean not the barbaric and inhumane slavery itself, but of the mechanisms used to control slaves, which was to incorporate “one of their own”, some-one who speaks the language of the slaves, and is himself, a slave. This is the mechanism that acted as the buffer system within Django Unchained, with the benefit for the master that the anger would be directed from the slaves towards Stephen. Stephen was placed in a position as the communicator between the master and the slaves whilst handling all the dirty work for Mr Candie, allowing Mr Candie, if he so chooses, to act friendly and kind amongst his slaves.

Whilst the BMA apparently believes it was their negotiations that led to this guardian system, I question to what level this was considered in terms of its ability to be misused and its potential manipulation of other more senior doctors to be used within this power structure.

I urge therefore that those taking up the role of the Guardian or the educational supervisors themselves, to consider fully how they may be in a vulnerable position and may be misused by those in power as a buffer system to project and divert blame and enforce a contract which 98% of junior voted against, and to please not wrongly believe, like Stephen did, that this contract has granted them with an actual position of power and influence in real organisational terms.